By Birdstrike M.D.

I think every Emergency Department has a patient like this.  Homeless Elvis came in to our ED at least once per day, for many years.  Sometimes he’d see each doctor, on each shift in an entire day.  By sheer numbers the amount of uninsured ED visits he accumulated over time was unbelievable.  None of us ever knew his real name, because he never had ID, and he insisted we call him “Elvis.”  His last known job was working as an Elvis impersonator, and due to his uncanny resemblance, this would have been no stretch.  We all knew “Elvis” had no real home, other than possibly our ED.   On one particular day, he surprised us all.

I had taken care of the guy, probably 500 times.  He had an extremely bad heart.  He was told that after a heart bypass, repeat bypass and multiple heart stents, that there was absolutely nothing anyone could do for it.  It was amazing he was even alive.  He would come to the ED, every day with the same complaint: “Chest Pain.”  Sometimes he actually had chest pain, sometimes he didn’t.  Sometimes his chest pain was from a heart attack, sometimes it wasn’t.  More often, Elvis wanted food, clothes, or shelter from the elements and most of all, company.  In our ED, he almost always got it.  He would routinely agree to an aspirin, EKG, and sometimes labs.  Almost never, anymore, would he agree to hospital admission, or stress testing, let alone a heart cath.  He must have politely signed hundreds of “against medical advice” release forms.  He never argued with anyone, made any demands or caused any trouble.  He had been coming to our ED longer than anybody that worked there.  The guy was a fixture of our ED and part of its soul and personality.  Some of us spent more Christmases, New Year’s Eves, and other holidays with Elvis, than with our own families.  I once overheard one of our veteran nurses tell a new employee, “Oh, don’t worry about Elvis.  He’ll grow on you.  Like mold.”

Not surprisingly, Elvis also had depression, in its most severe and chronic form.  Whether his situation led to his depression, or his severe depression rendered him unable to function, it is hard to say.  Rumor had it that he was married with children at one point and that they had left him and that he had lost all contact.  He refused to talk about any of it.  The only thing that helped his mood other than a warm blanket, meal tray and something for his pain was his antidepressant medication.  He had been on it for years.  Nothing else worked.  Sometimes he had a little bit of money to buy it, sometimes he didn’t.  Sometimes he’d get samples, sometimes he didn’t.

I actually liked seeing Elvis as a patient.  I knew him well and I knew exactly how to take care of him, since I had seen him so many times.  Seeing him was, in a strange way, a routine and comforting break during many a chaotic shift.  He was an easy patient, really.  Others got irritated, especially if they were new and didn’t know him well, and especially when the ED was busy.

One shift, we were incredibly busy with 30 or more patients waiting and only two doctors on duty.  The acuity was high.  We had traumas, and we weren’t a trauma center.  We had STEMIs and we had no cath-lab. We were buried.

In comes Elvis by ambulance, with his usual chief complaint of “Chest pain.”  I purposely let my partner Mike see him.  Mike was new to our ED and had just finished residency.  There’s no better time for him to get to know Elvis, I thought to myself.  Doctor Mike signed up to see Elvis and went in to see him.

A couple of hours later I looked in Elvis’ room, expecting to see the usual finished meal tray, tattered boots at the foot of the bed and a lump of a person sleeping with the sheet pulled over his head.  “What happened to Elvis?” I asked Mike.

“He signed out against medical advice a couple of hours ago,” said Mike.  “He completely refused a cardiac workup.  We gave him a bus pass and he asked if he could wait in the waiting room for a couple of hours.  He said he would never come back.”

“Oh, I should have told you about him.  He comes here all the time.  He has horrible, untreatable coronary disease and really, nothing helps him other than an aspirin, some morphine for his pain and maybe refilling his prescriptions.  Cardiology knows him well and agrees.  They’ve said there’s absolutely nothing else to offer him surgically.  They can’t believe he’s still alive.  He’s actually a sad case.  He’s homeless and lonely most of the time.  We’ve tried to set him up with social services, primary care, everything.  He’s just one of these guys that fell through every single crack in the system.  There’s no getting rid of Homeless Elvis.  He’s here to stay.  He’s harmless, really.”

“Oh, really?  I actually feel a little bit bad then.  I told him it’s not appropriate for him to be coming here three times every day for non-emergencies.  I had social work fill a month’s worth of his antidepressant for him, though.”

Interrupting us, somebody yelled from the waiting room, “HELP!  OUT IN THE WAITING ROOM!  SOMEBODY BRING A STRETCHER!  CODE IN THE WAITING ROOM!”

We ran through the double doors to the waiting room.  There was a person lying on the floor, motionless.  “Oh, my God, it’s Elvis!” I exclaimed.  We lifted him onto a stretcher and one of the techs hopped on and started chest compressions as we rolled quickly down the hall to one of our code rooms.  His heart must have finally given out, I thought to myself.  Into “code-mode” we clicked.

Pulse: none.

Monitor: V-tach.

“One, two, three….charging!”

BAM!  We sent a jolt of lightning through Elvis’ heart.

“Look, we’ve got a rhythm.  That was quick.  Check for a pulse,” I said.

“Got one!” said a nurse, as we shot through ACLS protocol.

“Let’s get a 12-lead.  Let’s see this MI,” I ordered.

His EKG was not what I expected.  There was no ST elevation, whatsoever.  There was no MI.  His QRS was wide, really wide, and definitely much greater than 100 ms.  That’s weird, I thought to myself.  “Let’s run a continuous 12 lead.  His ST segments have to go up.”

“Hey doc, check this out,” said one of the techs holding up a pill bottle from Elvis’ pocket.  “It’s empty.”

“Empty?” I asked, “What is it?”

“Am—,  amitri— something.  I don’t know how to say it,” he answered.

“Amitriptyline?” I asked.

“That’s it,” he answered.

“He ate the whole bottle?  He overdosed in the waiting room!?  What the….?” I said, shocked.  “We need some Bicarb.  Now, before he arrests again.  Get Doctor Mike in here.”

“Yeah, what’s up?” said Mike.

“Remember Elvis, your patient that signed out AMA about 2 hours ago?” I asked him.

“Yeah, what happened?  Did he have a heart attack in the waiting room, or something?” he asked, shocked.  “Good thing I had him sign out AMA.”

“No, actually he tried to kill himself.  He went into cardiac arrest after taking the whole bottle of amitriptyline you gave him.  We got him back, though.  For the moment, anyway,” I explained.

“You’ve got to be kidding me,” said Mike, shaking his head in disbelief.

Elvis was my last patient of that shift.  I felt like the life was sucked out of me.  I felt like I had coded a family member.  Many times we had kept Elvis alive, whether by providing a meal, treatment for his heart, or simply made his life better by providing pain control or shelter from the elements.  This time we saved his life in dramatic fashion.  I don’t know why, but despite that, I felt that I had failed, and miserably so.  Elvis went off to the ICU alive but in critical condition.  I went out the door and on with my life.

A few days went by and we didn’t hear anything about Elvis.  Then someone said he got transferred to the local University Hospital.  A few weeks later we called trying to find out what happened.  Nobody there seemed to remember him or know what happened.  They wouldn’t give us any information.  “HIPAA,” they said.  Did he take a turn for the worse and die, or remain in a coma?  Did he survive and take what Dr. Mike said to heart and refuse to come back to our ED?  Nobody knows.  All we know is that we never saw our Elvis again.

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This author does not divulge protected patient information or information from real life court cases.  Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients.  To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional.  Any opinions expressed here are of the author alone and not those of epmontly, WhiteCoat, my employer or any of the hospitals with which I am affiliated.

By Birdstrike M.D.

I was driving home from a night shift and the scorching sound of Texas guitars flamed out of my car speakers.  The group ZZ Top was old, but the song was new.  It went like this, “25 lighters on my dresser, yessir.  You know I gotsta get paid.”  Mostly, I was shocked that any members of the band ZZ Top were still alive, let alone putting out new music that was actually getting airplay.  Also strange, is that the song is a remake of an old rap song.  The lyric reminded me of a patient who I won’t name.  It would be a safe assumption that he was a gang member.  He wore saggy, baggy pants, and was heavily tattooed and shirtless.  He either spent 8 hours a day in the gym lifting weights, or ate a healthy diet of steroids.  If he had killed half as many people as his tattoos indicated, it was certainly in my best interest to keep him happy.  This was one patient satisfaction score I would ace.  I’ll call him Lighterman.

“Yo doc!  You gotta fix my hand, man,” Lighterman said in his gang accent.  He held up his bleeding hand.

“What happened?” I asked.

“I used my knife to open a bottle of some Robitussin to put in my beer and I slipped,” he said.  “My brother is home right now getting wasted on my stash.”

“Robitussin in your beer?” I asked, half amused.  “That could kill you, you know?”

“Aw yeah, boy.  It’ll light you up, man.  You should try it.  You a doctor!  You can have all you want, anytime, man.  You got it made,” he said.

“Uh, no.  I would never do that.  Let’s take a look.”  He had a 2 cm laceration on the back of his hand.  I prepped, draped, anesthetized and explored it.  “Looks like you’ve got a partial extensor tendon laceration,” I explained.  “It would be best to have it repaired by a hand surgeon.”

“No way.  I got deals to make and hearts to break, man.  Ha!” he laughed.

“I’ve heard that one before.  I’m not joking, though.  This is serious,” I said.

“You got 10 minutes and I’m gone, dog,” he said.

Suffice it to say that my best “against medical advice” warnings about limb-threatening bad outcomes and signed paperwork did nothing to dissuade him.  He showed no outward signs of drug or alcohol intoxication and certainly would not have consented to blood or urine testing to prove otherwise.  Although, his judgment was clearly very poor, he understood the risks of not getting the best treatment for his injury.  He just didn’t care.

“I don’t got time to go see your specialist, either,” he added.  “I trust you, man.   You look like that TV doctor from back in the day, Doogie Howser, only younger, smarter, with a bigger head and skinnier neck,” he said laughing.  “Sew on, man.  Get on it.  Plus, if you don’t do it, I’ll shoot you.”

“What?” I asked.

“Just kidding, I’d never shoot a doctor as good as you.  Ha!” said Lighterman.  “Here you go, man,” he said and pulled a handful of cigarette lighters out of his pocket.   “A little somethin’ for the effort.”

“No, that’s okay.  I don’t smoke.  I don’t drink or take drugs, either.  Neither should you.  I really don’t need a bunch of cigarette lighters.  Plus, we don’t accept tips here in the Emergency Department,” I answered.

“You don’t drink, smoke or take drugs!?  What do you do?  You’re a tough negotiator, boy!  You’re playin’ dumb.  It’s not enough is it?  Here you go.  All my stash,” and he emptied his pockets full of lighters on the counter.

I was completely clueless about why in the world he would have pockets overflowing with cigarette lighters, or why he would think they would make a good “tip”.  Exhausted at 4 am on a Saturday morning I didn’t really care either, so I stitched him and his extensor tendon, splinted him and arranged close follow-up with a hand surgeon he would likely never see.  I wasn’t happy with the medical-legal implications of sewing up his extensor tendon, but he didn’t leave me with any good options.  It seemed that my tendon repair would be better than no repair and without any follow-up.  Never knowing when someone might light a cigar on the golf course, I took one of the lighters and put it in my pocket for golf day.

From the room next door, my 50-year-old male patient who was brought in intoxicated and passed out peeked his head inside the curtain and said, “Doc.  I need some Dilaudid.  Plus, some Vicodin, please.”

“Joe.  Please, close the curtain.  You’re violating this patient’s privacy.  And by the way, we don’t treat alcohol intoxication with Dilaudid and Vicodin,” I answered.  In the room next door was his girlfriend, in her 20′s, who was also passed out intoxicated.  Her demographic sheet listed her occupation as “entertainer”.  Both were brought in by their friends who quickly dropped them off and went back out to party.  She was starting to wake up, too.

“I wanna get the f— out of here.  NOW!”  she started screaming.  “Somebody got a light?  I need a light!” and she pulled out a cigarette and popped it in the corner of her mouth.

The nurse corrected her, “No, ma’am!  This is a non-smoking campus.  You can’t smoke.  You’ll be arrested.”

I finished up sewing Lighterman’s hand and said my goodbyes.  He flashed me some extensive and involved gang-signs that I roughly translated as, “Thanks.”  He stood there waiting for his discharge papers.  He was the most appreciative patient of the night, by far.  He gave me 25 lighters more than any other patient that shift.  What the heck he thought I was going to do with a pile of lighters, I had no clue.  Sell them? I thought, and laughed.

“Make sure you see that surgeon,” I added, knowing it was futile.

“Don’t worry.  If I have any problems, I’ll have my lawyer call you.  He’s better than OJ’s lawyer,” Lighterman said.  “Just kidding, I’d never sue you.  You’re a good doctor.  I ain’t payin’ the bill, though.  Believe me on that one.”

“Oh, I believe you,” I said as I looked at his name in the computer.  He had registered under the name, “Michael Jordan,” except that was not his name, and he was not Michael Jordan.  He registered under a fake name on purpose.  “See you later…uh, Mike.”

I went in the back room to finish charting.  When I came out and looked around, all 3 rooms were empty.  Lighterman and the two others were gone.  “Where’d they go?” I asked the nurse.

“Once he left, the two others got up.  They both ran in his room as fast as they could and ran out of this ED like they were on fire,” she laughed.

“Maybe they were on fire, who knows?” I laughed.

“You know what was weird?  They both scooped up those lighters like they were full of gold.  I guess she really did need a cigarette.  What she was going to do with the other 2 handfuls of lighters, I don’t know.  Sell them?” she said chuckling.

“Yeah, for what, ten cents each?”  I said.  “Wow.  People never cease to amaze me.”

I shook my head and went in to see the first of the 25 patients now piled up waiting for me and introduced myself.  He was talking on his cell phone oblivious to my presence, so I interrupted and asked, “What can I do for you today, Sir?”

“Okay, I gotta go,” he said into the phone, “there’s some dude here trying to talk to me.”  He hung up.  “I’d like an inhaler, some cough syrup, a Z-pak, Tylenol on a prescription so Medicaid will pay for it, plus a work note for my sniffles.  That’s it.  I’m ready to go,” he said.  “By the way, that was crazy, wasn’t it?”

“What?” I asked.

“I can’t believe that guy tried to tip you with all those lighters full of crack.  That was insane!” he said laughing.  “You know how much he could’ve sold those for?  He must have really liked you.  And those two other kooks got away with the score of their lives.”

“Lighters full of what?” I asked

“Crack.  Cocaine!  That’s how the dealers hide their stash around here.  They empty out cigarette lighters and fill ‘em with crack.  They’re a lot less likely to get caught handing off a lighter than a bag full of crack, aren’t they?  Wow, you don’t get out much do you?” he asked.

“No, I don’t,” I answered.

“By the way, you gotta light?” he asked.

“No.  Actually, yes!” and like lightning I put my hand in my pocket, pulled out the lighter I forgot I had pocketed, threw it on the counter and called,

“Security!”

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This author does not divulge protected patient information or information from real life court cases.  Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients.  To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional.  Any opinions expressed here are of the author alone and not those of epmontly, WhiteCoat, my employer or any of the hospitals with which I am affiliated.